Late last year I was asked to see a lady in her 50s who had received a full facial treatment with a popular hyaluronic acid-based “skin booster” two months previously. On the same day she had also received Botulinum Toxin injections and treatment of the nasolabial folds with a different hyaluronic acid (dermal filler). This case study will document in chronological order a combination of what the patient experienced thereafter as well as details of how she was successfully managed for a delayed dermal filler-related infection. This patient will be referred to from here on as patient X. There is a short test at the end; so pay attention! As a provider of hyaluronic acid injections, you should know what to do.
Day 28 following treatment
patient X had developed an angry red rash over her whole face, up to her cheeks. Her main concern was a pronounced itch. Not wanting to divulge to her GP that she had received a cosmetic treatment, she attended, advising him that she had reacted to a “new cream”. Her GP prescribed cortisone cream (steroid), which helped with the itch, so much so, that the patient stopped using the cream after 3 days before switching to an emollient cream.
Patient X continued to see a recovery of this rash for the following seven days as she continued to apply emollient cream daily but then unfortunately saw the return of an even angrier red rash to both lower cheeks (see figure 1) 60 days following the initial treatment.
Day 60 following initial treatment
I reviewed the patient and made a differential diagnosis as follows:
- Delayed dermal filler-related implant infection.
- Hypersensitivity reaction
On reviewing the Expert Consensus on complications of Botulinum Toxin and Dermal Filler Treatment1, I learned that there these possibilities may represent a spectrum of symptoms rather than two discrete diagnoses. In any case, the initial treatment is the same except for one difference. The guideline suggests that if the infection or hypersensitivity presents more than two weeks after treatment, inflammatory markers should be used to guide response to antibiotics. As the reaction was localized to the patient’s face and she was systemically well, blood samples were not sent; allowing instead for a trial of first line antibiotics.
Based upon this guideline, the advice and management I provided was as follows:
- Avoid using steroid (oral or topical).
- Antibiotics: Clarithromycin 500mg twice per day and Moxifloxacin 400mg once per day. This patient is allergic to penicillin so I reassured her that neither of these was a penicillin.
- The affected area then needs to be reassessed (ideally, this should include comparison with the photos taken initially) on day 3 of antibiotics. “If there has been an improvement, the treatment plan is to continue on that regimen for another 11 days THEN review again. If response then is still incomplete, antibiotics may be continued up to 4 weeks in total.” If after the first 3 days of antibiotics there has not been a good response, we’ll need to switch to an alternative antibiotic regimen (clindamycin and tetracycline for 2-4 weeks), as per protocol (see figure 2).
To be pragmatic, i’ve included here the prices for this regimen, on a private prescription, according to the BNF (prices vary between pharmacies). Clarithromycin will cost £2 per day and Moxifloxacin will cost around £2.50 per day. So this treatment is likely to cost approximately £4.50 x 14 = £63.
I prescribed a five day supply and arranged a review appointment five days later due to the preferred follow-up day being on a weekend.
Day 65 following initial treatment
Both patient X and myself agreed that there was a significant improvement since day 60. She had tolerated the clarithromycin and moxifloxacin well. She agreed to complete the 14 day course as discussed previously, and I prescribed these antibiotics for a further nine days.
I also advised that I be contacted if the redness returned or became worse or, if it did not fully resolve on completion of the full 14 day course of antibiotics. I also reiterated the importance of completing the full course.
Day 69 following initial treatment
Unfortunately, at this review appointment, the patient appeared to have developed dermatitis on her face and both wrists. This rash was quite different from the previous rash as it was more generalized and less defined, with a dry looking surface. We discussed that the appearance was more in keeping with a dermatitis than infection, and that this was likely a side-effect of the antibiotics but was probably being exacerbated by her application of makeup and various creams to her face: a vicious cycle as the more redness she developed, the more makeup she applied to camouflage the redness and the more irritation and redness occurred as a result.
The patient had been using steroid cream on her wrists and I advised her to continue with this.
There was no return of the dark red spots on both sides of the lower face, which we had treated as dermal filler-related infection (figure 1). I reassured her that this was good news. By this stage, understandably, the patient was becoming very frustrated and upset by the symptoms she was experiencing.
Together we faced a difficult decision at this stage. Our only three options seemed to be:
- Break protocol for the filler infection and stop antibiotics early. This risked the return of an infection that was now contained, albeit, with dermatitis as a probable side effect of the medication.
- Switching to another antibiotic for at least 14 days whenever we were so close to completing the current course. Also, with this option there was a risk that the alternative regimen might not be as effective.
- Putting up with the generalised skin irritation and completing the course. The protocol states 10-14 days for this course- this review was on day nine, so finishing it the following evening would technically be a completion of the recommended treatment.
The patient agreed to continue with the antibiotics for 36 hours and thereby complete the full, recommended course. We discussed the following steps as a method of hopefully seeing an improvement in the dermatitis reaction.
- Keep makeup as minimal as possible including applying whenever just about to leave the house and removing as soon as she gets home.
- Diprobase ointment at night and cream by day. To stop using non-prescribed moisturisers until this settles as they can contain additives, which might further irritate her skin.
- Consider seeing her GP if following the course of antibiotics, the dermatitis does not begin to resolve.
I also reiterated that patient X should be vigilant in case there is a return of the angry rash that she saw initially, 60 days following her treatment; especially if it occurred around her lower face. We discussed that this occurrence could suggest incomplete treatment of the infection.
Day 74 following initial treatment
Patient X reported that she had had a “rubbish weekend” but at least the “makeup is no longer stinging”.
Day 76 following initial treatment
Patient X reported that the generalized redness had reappeared. Note that this was not the dark red spots which had appeared initially (figure 1). Again, I advised the patient to avoid makeup AND advised that a GP seeing her without knowing the full history may be tempted to prescribe steroid cream. I recommended that this misunderstanding should NOT be allowed to take place as a result of the GP not being aware of the true diagnosis. I recommended the avoidance of steroid cream until one month after the infection had settled.
Day 81 following initial treatment
Patient reported that all rashes were fully resolved.
Day 296 following initial treatment
Patient reports that there has been no reoccurrence of any facial rashes.
Thankfully the incidence of dermal filler-related infection is relatively low. With an increasing demand for dermal filler treatments however, the incidence is likely to increase over time. It is important therefore that medical and dental professionals are aware of how to treat this complication whether it arises in patients treated directly by them or by those working under their supervision. As with any rare complication, medical and dental professionals should be quick to ask for advice from a colleague with more experience should they be unsure as to how to proceed. Referral pathways for dermal filler-related complications are very unclear; it is advisable therefore that professionals who are unsure as to how to gain an expert opinion, liaise with either their aesthetics training academy or their local product specialist / sales rep for the product causing concern. Staphylococcus aureus is the most common bacteria to cause dermal filler-related infection1, and because of this, it does seem more likely that dermal filler-related infection is due to infection introduced either at the time of treatment or immediately thereafter (e.g. on the early application of makeup or other facial treatments) rather contaminated filler product.
In this case study, we discuss a delayed infection. The Expert Consensus defines a delayed reaction as one more than two weeks after the initial treatment with hyaluronic acid, but notes that the infection can occur many months later1. One theory as to how this occurs is that the bacteria forms an envelope (biofilm) around the hyaluronic acid, eventually causing an inflammatory reaction2.
The expert consensus recommends an aseptic technique for the application of any hyaluronic acid; whether dermal filler or skin booster. With the relatively higher number of injection sites normally required to administer skin boosters, it follows that the risk of infection is likely to be great with skin boosters compared to other treatments performed with hyaluronic acid. These steps are suggested:
- Avoid treating patients with signs of current infection, including skin infection.
- Remove makeup.
- Keep needles and syringes sterile throughout treatment.
- Use clean gloves. Avoid touching non-sterile surfaces during treatment e.g. clinic waste/sharps bucket, treatment couch, computer, outer packaging of dermal filler, fridge door.
- If using a cannula, avoid touching this on gloves.
- Clean the skin with an antiseptic such as chlorhexidine, then allow to dry for 20-30 seconds.
Clinical Procedure Vs. Beauty Treatment
Facial Aesthetics is widely offered by a variety of professionals. When performing these procedures, we soon realise that what we offer is not solely a “clinical procedure” but also, not solely a “beauty treatment”. Facial Aesthetics can be said to fall somewhere between these two practices. It is important therefore to understand the complexities of managing a complication in facial aesthetics, taking this into account. The patient in this case was adamant that she did not want her own GP to know what treatment she had received due to the stigma of receiving an aesthetic treatment. This level of perceived stigma will obviously vary but needs to be taken into account whenever considering how our aesthetics patient will potentially interact with other specialties; particularly if those specialties are unfamiliar with the products that we use. This patient found herself in a vicious cycle whereby the application of makeup, to cover up the adverse reaction she had suffered, appeared to be making the inflammatory response worse, necessitating the application of higher volumes of makeup to cover up an even more erythematous face. It’s important in these cases for the practitioner to be aware of the balance of issues in this scenario. We agreed in this case, that the patient should wear some makeup for an important event she was attending but was to wear it for the shortest duration possible and to avoid wearing any on the days before and after the event. By saying simply, “you must not wear any makeup” the patient may have had to either miss out on the significant event or, ignoring the practitioner’s advice, ended up deeper into the vicious cycle.
Dealing with complaints – make a change to your practice
It’s important, as well as dealing with a complaint, to demonstrate that you care enough about what happened to take steps to reduce the chances of such an event occurring again in future. In this case, the clinic where the initial treatment was carried out already had an aseptic technique protocol in place. It is important to realise that even with satisfactory aseptic technique, infection can still occur, but it makes sense to remind all staff, of this importance and to inform the patient who has been adversely affected, of what steps have been taken to reduce the chances of this happening again in future. Clinics should also consider handing out aftercare sheets (downloadable on our own online medical history form (link below). These aftercare sheets should highlight the need to avoid applying makeup to the face for at least 12 hours post-procedure in order to reduce the chances of developing a skin infection. We also agreed to have some further explanation of this risk added to the consent form used in the clinic where the treatment took place. A change in the wording has now been implemented on the Flourish App dermal filler consent form (see this link to my own clinic’s medical history form, which uses the same system).
The dermal filler complication section now reads:
- Bruising, bleeding, discomfort, itching for several days
- Rarely discolouration of the injection site, necrosis (death of skin), abscess formation, skin infection, granulomas (abnormal growth of skin), hypersensitivity and haematomas (large bruises) have been reported. Indurations or nodules may develop at the injection site if any of these symptoms persist for more than 1 week, consult with the doctor/dentist/nurse who has treated you
- When using dermal filler to treat frown lines, smile lines (nasolabials / nose-mouth lines) there is a very small risk of skin damage requiring plastic surgery or even irreversible blindness. Feel free to ask your practitioner what precautions they will take to minimise this risk
- Skin infection related to dermal filler is rare but likely to increase in incidence
- If this occurs, follow the advice contained within the Expert Consensus1 and within this case study
- If unsure, contact someone with more experience
- Reduce the risk of this occurring by observing an aseptic technique
- Ensure that your patients are aware that they must not apply makeup for at least 12 hours after receiving a treatment with any hyaluronic acid, especially a skin-booster
1) Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Inglefield, Collins, Duckett, Goldie, Huss, Paun, Williams (March, 2014). Part funded through an unrestricted educational grant from Merz Aesthetics UK).
2) Cassuto D, Sundaram H. A problem-orientated approach to nodular complications from hyaluronic acid and calcium hydroxylapatite fillers: classification and recommendations for treatment. Plastic and Reconstructive Surgery (Oct, 2013) 132;48-58S.
All of the medical, nursing, pharmaceutical staff and all at Merz Aesthetics for developing the Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Thanks to the patient that this case study refers to and the clinic where she was treated; both, although treated here anonymously, were happy to have this information shared so that others might benefit from any lessons learned.
Dr Michael D Aicken firstname.lastname@example.org